Public Record
Villa at Borgess Place
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 101
- Avg. residents per day
- 79.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 82
- Inspections on file
- 14
- Last inspection
- 2026-03-26
*CMS
*CMS
*CMS
Citations
82 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0627Generalpotential for harm
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0847Generalpotential for harm
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0578Generalpotential for harm
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- 0605Generalpotential for harm
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Seriousactual harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0686Seriousactual harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0803Generalpotential for harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0940Generalpotential for harm
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0232Generalpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0584Generalpotential for harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0758Generalpotential for harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0813Generalpotential for harm
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0887Generalpotential for harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0699Generalpotential for harm
Provide care or services that was trauma informed and/or culturally competent.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection4 deficiencies
- View inspection reportInspection6 deficiencies
- View inspection reportInspection25 deficiencies
- View inspection reportInspection25 deficiencies
- View inspection reportInspection7 deficiencies
- View inspection reportInspection1 deficiency
- View inspection reportInspection3 deficiencies
- View inspection reportInspection3 deficiencies
- View inspection reportInspection20 deficiencies
- View inspection reportInspection20 deficiencies
Showing the 10 most recent inspections. 4 earlier inspections are also on record.
FAQ
Questions and answers
- What is Villa at Borgess Place?
- Villa at Borgess Place is a Medicare- and Medicaid-certified nursing home in Kalamazoo, MI, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 235289.
- What is the CMS rating for Villa at Borgess Place?
- Villa at Borgess Place has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Villa at Borgess Place have?
- Villa at Borgess Place is certified for 101 beds. It serves an average of 79.3 residents per day.
- How many citations does Villa at Borgess Place have?
- Villa at Borgess Place has 82 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Villa at Borgess Place last inspected?
- Villa at Borgess Place was last inspected on March 26, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/235289-villa-at-borgess-place